Anxiety and Callous-Unemotional Traits: Physiological and

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Anxiety and Callous-Unemotional Traits:Physiological and Behavioral Responses to Others'DistressKathleen I. CrumFlorida International University, [email protected]

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FLORIDA INTERNATIONAL UNIVERSITY

Miami, Florida

ANXIETY AND CALLOUS-UNEMOTIONAL TRAITS: PHYSIOLOGICAL AND

BEHAVIORAL RESPONSES TO OTHERS’ DISTRESS

A dissertation submitted in partial fulfillment of

the requirements for the degree of

DOCTOR OF PHILOSOPHY

in

PSYCHOLOGY

by

Kathleen Isabel Crum

2016

ii

To: Dean Michael R. Heithaus

College of Arts, Sciences and Education

This dissertation, written by Kathleen Isabel Crum, and entitled Anxiety and Callous-

Unemotional Traits: Physiological and Behavioral Responses to Others' Distress, having

been approved in respect to style and intellectual content, is referred to you for judgment.

We have read this dissertation and recommend that it be approved.

_______________________________________

Stacy L. Frazier

_______________________________________

Maureen C. Kenny

_______________________________________

Erica D. Musser

_______________________________________

Jonathan S. Comer, Major Professor

Date of Defense: July 1, 2016

The dissertation of Kathleen Isabel Crum is approved.

_______________________________________

Dean Michael R. Heithaus

College of Arts, Sciences and Education

_______________________________________

Andrés G. Gil

Vice President for Research and Economic Development

and Dean of the University Graduate School

Florida International University, 2016

iii

© Copyright 2016 by Kathleen Isabel Crum

All rights reserved.

iv

DEDICATIONS

To my loving family, a team I would never trade; to my dear friend Tiffany, who

crosses this finish line with me in my heart; and to everyone in the arena, wondering how

much they dare to achieve.

v

ACKNOWLEDGMENTS

I am immensely grateful for the support and guidance provided by mentors,

committee members, colleagues, and friends throughout this process. Without my major

professor, Dr. Jonathan Comer—who helped me realize my potential and taught me to

never give up—and my team of dedicated research assistants, Christina Flores and

Michelle Lorenzo, this project would not have been possible.

This project was generously supported by an Elizabeth Munsterberg Koppitz

Fellowship in Child Psychology, awarded to Kathleen Isabel Crum by the American

Psychological Foundation (APF). Study findings and conclusions are those of the author,

and do not necessarily represent the views of the APF.

vi

ABSTRACT OF THE DISSERTATION

ANXIETY AND CALLOUS-UNEMOTIONAL TRAITS: PHYSIOLOGICAL AND

BEHAVIORAL RESPONSES TO OTHERS’ DISTRESS

by

Kathleen Isabel Crum

Florida International University, 2016

Miami, Florida

Professor Jonathan S. Comer, Major Professor

Research documents considerable anxiety-related heterogeneity in youth with callous-

unemotional traits (CU), a pattern of callousness and shallow emotionality (Frick & Ellis,

1999) associated with lasting impairment (Fontaine et al., 2011). This heterogeneity may

relate to behavioral differences, with the presence of both CU and anxiety associated with

increased questionnaire-based reports of aggression and/or historical documentations of

past aggression (Kahn et al., 2013). Anxiety in CU youth is associated with greater

attention to others’ distress cues (Kimonis et al., 2012) compared to CU-only

counterparts, in contrast to the decreased distress-cue attentiveness thought to contribute

to aggression in CU youth (Dadds et al., 2011). Through its association with

improvements in CU youths’ ability to detect others’ distress, anxiety may heighten

autonomic activity associated with emotional processing, in contrast to the dampened

autonomic activity observed in CU youth (de Wied et al., 2012). It is possible that CU

associations with distress-cue recognition and parasympathetic-based emotion-regulation

vary as a function of anxiety, and in turn are associated with aggression. The present

study, conducted with a sample of youth ages 7-13 (N=45), incorporated laboratory tasks

vii

and self- and caregiver-report questionnaires to assess the extent to which child anxiety,

traumatic stress, CU, and their interactions, predict observed aggressive behavior toward

other children and perceptions of others’ emotions while experimentally manipulating

distress-cue salience. Exploratory analyses considered parasympathetic activity that may

associate with observed relationships. Overall, results align with non-experimental

research suggesting that CU is associated with greater aggression in the presence of

anxiety (Fanti et al., 2013), and clarify that anxiety moderates the effect of CU on

aggression, but only in the absence of distress cues from a potential victim. Results also

hint that relationships between anxiety and parasympathetic responses to others’ distress

may help explain anxiety-related heterogeneity in CU youths’ aggression. Findings

suggest that children with CU and anxiety may benefit from emotional training to

anticipate others’ distress and identify distress cues. In aggressive situations involving

these youth, increasing others’ distress-cue salience may attenuate violence. Future

research must further investigate emotional processing deficits, and their role in the

development of aggression, among CU youth with anxiety.

viii

TABLE OF CONTENTS

CHAPTER PAGE

I. INTRODUCTION .............................................................................................1

CU Traits ............................................................................................................1

Heterogeneity in CU ..........................................................................................2

CU and Anxiety .................................................................................................3

Anxiety and Emotional Processing in CU .........................................................5

Impact of anxiety on attention biases in CU ................................................7

Links between anxiety and physiological response in CU ..........................8

Impact of anxiety on behavioral and physiological responses to others’

distress in CU ...............................................................................................9

Project Aims and Hypotheses ..........................................................................10

II. METHODOLOGY ..........................................................................................15

Participants and Recruitment ...........................................................................15

Procedures and Measures .................................................................................16

Analytic Plan ....................................................................................................22

III. RESULTS ........................................................................................................24

Addressing Aim Ia: Elucidating the interactive effects of CU and anxiety

on aggression ...................................................................................................25

Addressing Aim Ib: Elucidating the interactive effects of CU and traumatic

stress on aggression..........................................................................................25

Addressing Aim IIa: Investigating the interactive effects of CU and anxiety

on aggression in the presence versus absence of distress cues ........................25

Addressing Aim IIb: Investigating the interactive effects of CU and

traumatic stress on aggression in the presence versus absence of distress

cues ..................................................................................................................28

Addressing Aim IIIa: Elucidating the main and interactive effects of CU

and anxiety on perceptions of a potential victim’s emotional state in an

experimental context ........................................................................................28

Addressing Aim IIIb: Investigating the main and interactive effects of CU

and traumatic stress on perceptions of a potential victim’s emotional state

in an experimental context ...............................................................................30

Addressing Aim IVa: Elucidating the main and interactive effects of CU

and anxiety on parasympathetic response to others’ distress...........................31

Addressing Aim IVb: Elucidating the interactive effects of CU and

traumatic stress on parasympathetic-based response to others’ distress ..........33

IV. DISCUSSION ..................................................................................................33

Overview ..........................................................................................................33

Aggression .......................................................................................................34

Perceptions of Peer Emotions ..........................................................................35

ix

Physiological Responses ..................................................................................36

Trauma-related Findings ..................................................................................37

Clinical Implications ........................................................................................38

Limitations .......................................................................................................38

Future Directions .............................................................................................41

Summary and Conclusions ..............................................................................41

REFERENCES ............................................................................................................43

APPENDICES .............................................................................................................54

VITA ............................................................................................................................81

x

LIST OF TABLES

TABLE PAGE

1. Descriptive statistics……………………….…………………………….….58

2. Zero-order correlations between study variables......…………………….….59

3. Coefficients for the SuperBuilder hierarchical regression models predicting

aggression, with anxiety as moderator……………………………………....60

4. Coefficients for the SuperBuilder hierarchical regression models predicting

aggression, with traumatic stress as aa moderator…………………………..61

5. Coefficients for the hierarchical regression models perceptions of simulated

opponent’s emotions in the absence of a distress cue, with anxiety as a

moderator………………………………………………..…………………..62


opponent’s emotions in the presence of a distress cue, with anxiety as a

moderator……………………………………………………………...…….64

7. Coefficients for the hierarchical regression models predicting changes in

perceptions of simulated opponent’s emotions, with anxiety as a

moderator…………………………………………………………………....66


opponent’s emotions in the absence of a distress cue, with traumatic stress

as a moderator……………...………………………………………………..68


opponent’s emotions in the presence of a distress cue, with traumatic stress

as a moderator……………………………………………………………….70

10. Coefficients for the hierarchical regression models predicting changes in

perceptions of simulated opponent’s emotions, with traumatic stress as a

moderator…………………………………………………………………....72

11. Coefficients for hierarchical regression models predicting parasympathetic

responses, with anxiety as a moderator……………………………………..74

12. Coefficients for HLM predicting RSADistress scores across time, with CU

and anxiety as moderators…………………………….…………………….75

13. Coefficients for hierarchical regression models predicting parasympathetic

responses, with traumatic stress as a moderator…………….…………..….76

xi

14. Coefficients for HLM predicting RSADistress across time, with CU and

traumatic stress as moderators……………………………...………………77

xii

LIST OF FIGURES

FIGURE PAGE

1. Excerpts from the SuperBuilder game play simulation. Participants were

told they were building the red brick skyscraper, while their opponent was

building the yellow skyscraper……………………………………...……….55

2. Explanation of SuperBuilder sound blast levels presented to the child

participant……………………………………………………………………56

3. Neutral and distress messages, respectively, sent from the SuperBuilder

simulated opponent to the child participant………………………..………...57

4. Visual depiction of statistical models………………………………..……....78

5. Graph depicting the interactive relationship between CU and anxiety when

predicting aggression in the absence of a distress cue…………………….....79

6. Graph depicting the relationships between respiratory sinus arrhythmia and

caregiver-reported child anxiety scores on the MASC across the five

distress-condition epochs in the Distress Response task………...…………..80

xiii

LIST OF ACRONYMS AND ABBREVIATIONS

American Psychiatric Association APA

Antisocial behavior AB

Attention Deficit-Hyperactivity Disorder ADHD

Callous-unemotional traits CU

Central nervous system CNS

Child PTSD Symptom Scale CPSS

Conduct problems CP

Electrocardiogram EKG

Full-scale Intelligence Quotient FSIQ2

Hierarchical linear modeling HLM

Hostile attribution bias HAB

Inventory of Callous-Unemotional Traits ICU

Lower limit of 95% confidence interval LLCI

Medium Med

Missing completely at random MCAR

Multidimensional Anxiety Scale for Children, Second Edition MASC

Parasympathetic nervous system PNS

Peer Perception Scale PPS

Posttraumatic Stress Disorder PTSD

Respiratory sinus arrhythmia RSA

Standard deviation SD

Standard error SE

Statistical Package for the Social Sciences SPSS

xiv

Upper limit of 95% confidence interval UCLI

Wechsler Abbreviated Scale of Intelligence, Second Edition WASI-II

1

I. INTRODUCTION

Research documents considerable heterogeneity in youth presenting with callous-

unemotional (CU) traits, a pattern characterized by callousness, shallow emotionality,

and a lack of guilt following transgressions (CU; Frick & Ellis, 1999). Empirical work

suggests that anxiety-related heterogeneity in youth showing CU traits may be related to

meaningful differences in associated aggressive behavior, with the presence of both CU

traits and anxiety associated with a specific pattern of emotional processing deficits and

higher levels of aggression than children with just CU traits (Docherty, Boxer,

Huesmann, O’Brien, & Bushman, 2015; Euler et al., 2015; Fanti, Demetrious, &

Kimonis, 2013; Humayun, Kahn, Frick, & Viding, 2014; Kahn et al., 2013; Kimonis,

Skeem, Cauffman, & Dmitrieva, 2011; Lee, Salekin, & Iselin, 2010; Rosan, Frick,

Gottlieb, & Fasicaru, 2015). However, much of this research has relied exclusively on

questionnaire reports of aggressive behavior rather than observed aggressive behavior

(e.g., Kimonis et al., 2011; Lee et al., 2010), and has not examined how anxiety and CU

traits predict child aggression in the context of experimentally manipulated distress cue

salience from potential victims. Much remains to be learned about the processes

underlying observed associations between anxiety, CU traits, and aggressive behavior

among youth in order to optimally inform taxonomy questions and intervention efforts.

CU Traits

Considerable evidence documents the occurrence of children with serious

behavior problems who exhibit callousness, shallow emotionality, and a lack of guilt

following transgressions (i.e., CU traits; Frick & Ellis, 1999). Such CU traits constitute a

2

profile now recognized in leading psychiatric taxonomies (e.g., American Psychiatric

Association [APA], 2013), affect roughly one-third of youth with behavior problems

(Christian et al., 1997), and are associated with significant social and behavioral

impairment across the lifespan (Fontaine et al., 2011; Lynam et al., 2007; Obradovic,

Pardini, Long, & Loeber, 2007), and although they have been traditionally

conceptualized in the context of conduct disorder, emerging empirical work supports

consideration of CU traits as a transdiagnostic construct (Herpers, Rommelse, Bons,

Buitelaar, & Scheepers, 2012; Herpers, Klip, Rommelse, Greven, & Buitelaar, 2016;

Moran et al., 2009).

There is now strong evidence that children showing CU traits differ in important

ways from children with behavioral problems who do not show CU traits, and from

children without behavioral problems. For example, relative to peers, CU youth exhibit

antisocial behavior (AB) that is more severe, stable, and varied in nature (Frick, Kimonis,

Dandreaux, & Farell., 2003b; Frick & Dantagnan, 2005), show higher levels of reactive

(lashing out in response to perceived provocation) and proactive (calculated, goal-

directed aggression in the absence of anger; Dodge & Coie, 1987) aggression (Fanti,

Frick, & Georgiou, 2009; Lozier, Cardinale, VanMeter, & Marsh, 2014; Marsh et al.,

2013; Waschbusch et al., 2004), and show diminished or varied responsiveness to

traditional behavioral treatments targeting AB (Hawes, Price, & Dadds, 2014b;

McDonald et al., 2011; Waschbusch et al., 2007) relative to children without CU traits.

Heterogeneity in CU

Much remains to be learned about pathways leading to AB among youth showing

CU traits. Given physiological, temperamental, and cognitive differences associated with

3

CU, it has been proposed that the AB of children with CU arises from a separate pathway

relative to the AB of children without CU (Frick et al., 2003a). Moreover, it is unclear

whether the same mechanisms underlie AB development for all children with CU, or

whether multiple distinct pathways systematically eventuate in CU profiles. Through its

relationship with causal pathways to AB, heterogeneity associated with underlying

processes in CU likely contributes to mixed intervention response.

CU and Anxiety

Evidence suggests that children with CU constitute a heterogeneous population, with

some but not all susceptible to anxiety, which in turn is associated with increased

dysfunction and impairment. Importantly, analogous to primary and secondary variants of

psychopathy in adults (Karpman, 1948; Skeem, Poythress, Edens, Lilienfeld, & Cale,

2003), whereas the majority of youth showing CU traits do not show elevated levels of

anxiety, a subset of CU youth do, and elevated anxiety appears to alter the presentation of

CU traits in several key ways. Among children with CU, anxiety has been associated with

greater questionnaire-based reports of impulsivity and externalizing behavior problems,

as well as higher reports of aggression and delinquency (Kahn et al., 2013; Rosan et al.,

2015; Vaughn et al., 2009), especially reactive aggression (Fanti et al., 2013), a more

extensive criminal offense record (Kimonis et al., 2011), and increased reports of

depressive and psychotic symptoms (Docherty et al., 2015; Vaughn et al., 2009) relative

to CU youth without anxiety. These anxiety-related differences hold true despite

comparable levels of CU traits, although some studies have noted increased (Kimonis et

al., 2011; Lee et al., 2010) or decreased (Euler et al., 2015) CU trait severity among youth

who show anxiety symptoms relative to CU youth without anxiety. Anxiety may interact

4

with CU in important ways, but the nature of such interactions and their impact on youth

aggressive behavior remain unclear, impeding the identification of tailored treatment

targets, and hindering efforts to address the unique needs of children at various points on

these continua. Moreover, and importantly, research examining interactions between CU

and anxiety and their effects on AB has relied almost exclusively on questionnaire reports

of child aggressive behavior (e.g., Fanti et al., 2013; Kahn et al., 2013, Rosan et al.,

2015), and the studies that used criminal records did not assess aggression in an

experimental context (e.g., Kimonis et al., 2011; Lee et al., 2010), which limits

interpretations and cannot rule out issues related to reporter biases, shared method

variance, and external circumstances.

Of note, several studies have observed greater trauma exposure among CU youth

experiencing anxiety symptoms relative to their counterparts without anxiety (Euler et al.,

2015; Kahn et al., 2013; Kimonis et al., 2012; Tatar et al., 2012). Trauma is central to

theory underlying origins of primary and secondary variants in psychopathy (e.g., Porter,

1996), and may be a particularly relevant factor in the affective and behavioral

characteristics of children with CU and anxiety, considering research suggesting that

traumatic stress-related emotional numbing symptoms link violence exposure and

delinquency (Allwood, Bell, & Horan, 2011), and often co-occur with

hypervigilance/hyperarousal symptoms (Weems, Saltzman, Reiss, & Carrion, 2003).

Furthermore, trauma-exposed youth show a specific pattern of emotional processing

abnormalities, including an attentional bias towards threat (Dalgleish, Moradi, Taghavi,

Neshat-Doost, & Yule, 2001), enhanced identification of fearful faces (Masten et al.,

2008), and heightened sympathetic nervous system activity (see Teicher, Andersen,

5

Polcari, Anderson, & Navalta, 2002). It is worthwhile to assess the degree to which the

aggressive reactivity and internalizing symptoms (e.g., Docherty et al., 2015; Fanti et al.,

2013) reported by CU youth experiencing anxiety symptoms may actually represent

traumatic stress symptoms. Thus far, trauma exposure and traumatic stress symptoms

have been examined as clinical correlates differentiating variants of CU youth with

respect to anxiety (e.g., Humayun et al., 2013; Kimonis et al., 2012); the potential for

traumatic stress to moderate the link between CU and observed aggression in the context

of experimentally manipulated distress cues has not been explored.

Anxiety and Emotional Processing in CU

Anxiety-related variations in CU presentation may be a result of differences in

emotional processing across affected youth, as deficits in emotional processing are

thought to facilitate the development of AB, including aggression, in CU youth (Blair et

al., 2006). Child CU traits are associated with deficits in distress cue detection and

recognition, as well as emotional responding (e.g., Blair et al., 2005; Muñoz, 2009;

Woodworth & Waschbusch, 2008) that are susceptible to correction via increases in

distress cue salience (Dadds et al., 2006; Dadds, El Masry, Wimalaweera, & Guastella,

2008; van Baardewijk et al., 2009). Child CU traits have also been associated with

deficits in physiological reactions to distress-related cues as indexed by correlates of

parasympathetic and sympathetic activity, an important factor in emotional responding

(e.g., Blair et al., 2005; de Wied, van Boxtel, Matthys, & Meeus, 2012). These deficits in

recognizing and responding to others’ emotions correspond with reported deficiencies in

cognitive and affective empathy (e.g., Dadds et al., 2009)—the ability to identify and

match others’ emotional states, respectively (see Hoffman, 1984).

6

Attention to, and interpretation of, others’ emotions influences affective matching

of emotional states and, ultimately, emotional responding (Eisenberg et al., 2009; 2010).

In addition to deficiencies in cognitive empathy—that is, accurately identifying others’

distress-related emotions (Eisenberg & Fabes, 1990; Hoffman, 1984)—CU youth show a

pattern of hostile social cognition (see Frick, Ray, Thornton, & Kahn, 2014 for a review).

Youth with CU traits downplay the effects of their aggression on victims in hypothetical

conflict situations, reporting less concern for victims’ suffering, and endorsing social

goals focused on dominance and forced respect (Pardini, 2011; Pardini & Byrd, 2012).

When children with CU experience anxiety symptoms, they may be particularly at risk

for difficulties accurately identifying others’ emotions, as anxiety is associated with its

own unique pattern of social-cognitive biases, including biased attention towards threat-

related stimuli (Taghavi, Moradi, & Neshat-Doost, Yule, & Dalgleish, 2000) and a

tendency to interpret neutral stimuli as negative or threatening (Reid, Salmon, &

Lovibond, 2006). Although Kimonis and colleagues (2012) examined attention to distress

cues among children with CU and anxiety using distressing pictures in a dot-probe task,

the extant literature on anxiety in children with CU traits has not investigated perceptions

of peer emotion in experimental tasks approximating social interactions.

Understanding these emotional deficits is essential to prevention of AB among

children with CU traits, and research has shown the importance of potential victims’

distress cue salience in reducing emotion recognition deficits and altering aggressive

behavior in CU youth. Increased salience of others’ emotional cues has been linked to

increased accuracy of emotion recognition among CU youth, perhaps as a function of

attention to distress cues (Dadds et al., 2012). Indeed, when children are specifically

7

instructed to attend to emotional cues indicating others’ distress, and when distress cue

salience itself is increased (Blair, Colledge, Murray, & Mitchell, 2001), discrepancies in

distress-related emotion recognition between youth with and without CU traits are

reduced (Dadds et al., 2008). Increases in others’ distress cue salience have also been

associated with a decrease in the strength of the relationship between CU traits and

aggression (van Baardewijk et al., 2009). However, it remains unclear how anxiety-based

heterogeneity may affect associations between CU, aggression, others’ distress cue

salience, and physiological and behavioral responses to others’ emotions, as well as

perceptions of others’ emotions.

Impact of anxiety on attention biases in CU.

By signaling the potential for a variety of links between emotional processing and

CU traits, anxiety-based differences in attention to others’ distress cues may have

important implications for understanding links between CU and aggressive behavior, and

for developing informed treatment targets. Indeed, evidence suggests that anxiety in CU

youth alters emotional processing, and points to variation in the processes underlying the

cognitive, temperamental, and behavioral styles typical to CU traits. Among youth with

high levels of CU, anxiety is associated with greater attention to others’ distress cues

(Kimonis, Frick, Cauffman, Goldweber, & Skeem, 2012) than CU-only counterparts, in

contrast to the decreased attentiveness to these cues thought to contribute to AB in CU

youth (Dadds et al., 2011). Only one existing study has examined attention to others’

distress cues as a function of CU and anxiety (Kimonis et al., 2012), and while Kimonis

and colleagues’ findings provide preliminary information on patterns of emotional

deficits among CU youth, further research incorporating observational paradigms is

8

needed to examine how such anxiety-CU interaction patterns may influence

corresponding behavioral heterogeneity.

Links between anxiety and physiological response in CU.

Attentional differences accompanying anxiety in children with CU may be

directly associated with corresponding differences in physiological processes, which may

in turn affect clinical presentation and intervention response. Despite the lack of research

in this area, anxiety in CU youth may result in distinct physiological profiles in response

to others’ distress. As anxiety is associated with improvements in the ability of CU youth

to detect others’ distress cues (Kimonis et al., 2012), anxiety may indirectly heighten

related autonomic activity associated with emotional processing, in contrast to the

dampened parasympathetic and sympathetic activity typically observed in CU youth

(e.g., Anastassiou-Hadjicharalambous & Warden, 2008b; Blair, 1999; de Wied et al.,

2012; Muñoz, Frick, Kimonis, & Aucoin, 2008). Further, neural abnormalities in the

form of limited amygdala function (e.g., Blair et al., 2006; Jones, Laurens, Herba, Barker,

& Viding, 2009; Lozier et al., 2014) are associated with the “fearlessness” commonly

ascribed to youth with high levels of CU (e.g., Pardini, 2006). Fearlessness is

contradictory, however, to the worry and fears associated with chronic, trait-like anxiety

in youth with CU (e.g., Fanti et al., 2013). It may be that anxiety lessens these CU-related

abnormalities, reducing the blunted parasympathetic and sympathetic activity observed in

non-anxious children with CU traits. Thus far, no research has explored relationships

between CU, anxiety, and physiological response to others’ distress.

9

Impact of anxiety on behavioral and physiological responses to others’ distress in

CU.

Considering the potential and observed alterations in emotional processing

associated with anxiety in children with CU, it is possible that CU associations with

distress cue recognition and with physiological correlates of emotional response and

regulation vary as a function of anxiety, and in turn are associated with aggressive

behavior in important ways. Emotional processing and physiological correlates appear to

play a central role in driving behavioral responses to fear or distress in other individuals.

Indeed, accurate emotion identification and optimal levels of affective arousal—

facilitated by matching of affective states—are required to elicit prosocial responses to

others’ distress such that a lack of affective arousal—that is, an affective response to

others’ distress, thought to be facilitated by physiological activity—precludes prosocial

behavior (Eisenberg & Fabes, 1990; Eisenberg et al., 2010). On the other hand, overly

high levels of affective arousal are associated with personal distress, which may even

encourage aggressive behavior towards the perceived cause of distress, or withdrawal

from the distressing stimulus (Eisenberg & Eggum, 2009; Eisenberg et al., 2010). If

anxiety enables children with CU to attend to and recognize others’ distress more easily,

or enables children with CU to experience heightened physiological response to others’

distress, differences in behavior should be apparent; however, the manner in which

differences in emotional processing associated with anxiety are linked to aggressive

behavior is thus far unexamined. Importantly, existing research on relationships between

CU, anxiety, and aggression has relied almost exclusively on questionnaire measures,

rather than observed measures of aggression (e.g., Rosan et al., 2015), and no existing

10

research has examined these relationships in an experimental context; thus the complex

interplays between these factors remain unclear.

Improved understanding of the potential pathways by which emotional processing

is linked to aggression among children with CU and anxiety may lie in investigating the

role of distress cue salience (e.g., Kimonis et al., 2012). By intensifying others’ emotional

cues and reducing their ambiguity, increases in the salience of distress cues may

influence the manifestation of aggression among children with CU and anxiety.

Experimental manipulation of distress cues in the context of social interaction is needed

to clarify the role of emotional processing in the heightened aggression documented in

children with CU and anxiety. Given this theoretical and empirical background, it is

possible that anxiety significantly alters the relationship between CU and empathy-related

responding, shaping underlying processes that contribute to behavioral and social

impairment.

Project Aims and Hypotheses

The overall goal of this work is to examine the complex interplays between child

CU and anxiety in predicting aggressive behavior, to examine how the salience of others’

distress cues affects links between CU, anxiety, and aggression, and to consider

physiological processes—specifically, parasympathetic activity associated with emotion

regulation—that may correlate with such associations. The research incorporated an

experimental manipulation in a sample of youth ages 7 to 13 (N=45), incorporating

laboratory tasks and self- and caregiver-report questionnaires to assess the extent to

which child anxiety, traumatic stress symptoms, CU traits, and their interactions, predict

observed aggressive behavior toward other children and perceptions of others’ emotions

11

while experimentally manipulating the salience of distress cues from the other child.

Observations of aggressive behavior were collected in the context of a competitive game

simulation in which, unbeknownst to participating youth, the opponent child against

whom participants could aggress was in fact a programmed computer simulation.

Exploratory analyses further considered parasympathetic functioning and regulation that

may associate with observed relationships. By enhancing the field’s understanding of

anxiety-related heterogeneity and its interaction with CU, and examining the intricate

relationships between underlying attentional and physiological processes and aggression

in children, the current study can meaningfully advance theoretical models of CU and lay

an empirical foundation for targeted treatment development. Further, the current study

can lay the groundwork for future translational investigations of physiological processes

mediating emotional processing abnormalities in CU youth.

•Aim Ia: Elucidate the interactive effects of CU and anxiety on behaviorally

observed aggression in an experimental context. Hypothesis: Given the growing body of

literature documenting a subset of children with CU traits who show significant anxiety

and increased questionnaire-based reports of aggression (e.g., Docherty et al., 2015,

Rosan et al., 2015) and more extensive criminal records (Kimonis et al., 2011), it was

hypothesized that child anxiety will moderate the impact of CU severity on behaviorally

observed aggression (regardless of distress cue salience), such that higher levels of child

anxiety would be associated with a stronger link between CU and observed aggression.

•Aim Ib: Elucidate the interactive effects of CU and traumatic stress symptoms on

behaviorally observed aggression. Hypotheses: Given research documenting more

extensive trauma histories among children with CU and anxiety than their CU-only

12

counterparts (e.g., Euler et al., 2015), along with literature indicating potential overlap

between callousness and posttraumatic emotional numbing symptoms (Allwood et al.,

2011), it was hypothesized that among trauma-exposed youth, traumatic stress symptom

severity will moderate the impact of CU severity on behaviorally observed aggression

(regardless of distress cue salience), such that higher levels of traumatic stress would be

associated with a stronger link between CU and observed aggression.

•Aim IIa: Investigate the extent to which the interactive effects of CU and anxiety

on observed aggression vary relative to the salience of a potential victim’s distress.

Hypotheses: It was expected that CU severity would be strongly associated with observed

aggression when the salience of a potential victim’s distress is manipulated to be absent,

but would not be associated with observed aggression when the potential victim’s distress

was manipulated to be salient (van Baardewijk et al., 2009). It was expected that the

predictive value of the interaction between CU and anxiety would differ in the presence

versus absence of others’ distress cues, given the unique pattern of emotional deficits

observed among youth with CU and anxiety (Kimonis et al., 2012).

•Aim IIb: Investigate the extent to which the interactive effects of CU and

traumatic stress symptoms on observed aggression vary relative to the salience of a

potential victim’s distress. Hypotheses: It was expected that the predictive value of the

interaction between CU and traumatic stress symptoms would differ in the presence

versus absence of others’ distress cues, given the trauma histories reported among youth

with CU and anxiety (e.g., Kahn et al., 2013), and the emotional deficits observed among

youth with posttraumatic stress (e.g., Dalgleish et al., 2001; Masten et al., 2008).

13

•Aim IIIa: Elucidate the main and interactive effects of CU and anxiety on

perceptions of a potential victim’s emotional state in an experimental context.

Hypothesis: Given research documenting reductions in emotion recognition deficits (e.g.,

Dadds et al., 2006) with increased distress cue salience among CU youth, it was expected

that CU severity would not be associated with ratings of the simulated opponent’s affect

ratings in the absence of a distress cue, but that in the presence of a distress cue, CU

severity would be associated with increased ratings of the simulated opponent’s negative

affect, and decreased ratings of the simulated opponent’s neutral and positive affect. It

was further expected that anxiety would moderate the effect of CU severity on ratings of

the simulated opponent’s distress-related emotions. Specifically, it was predicted that

higher levels of child anxiety would be associated with a stronger link between CU and

ratings indicating the simulated opponent’s negative affect, such that greater anxiety was

associated with higher ratings of these emotions, given literature indicating increased

attention to distress cues (Kimonis et al., 2012) among children with CU and anxiety. It

was also expected that CU severity would be associated with changes in ratings of the

opponent’s negative affect, but that anxiety would moderate the effect of CU severity on

such changes. Specifically, it was predicted that higher levels of child anxiety would be

associated with a stronger link between CU and changes in perceptions of opponents’

negative affect, given the increased attention to distress cues (Kimonis et al., 2012)

observed among children with CU and anxiety.

•Aim IIIb: Investigate the main and interactive effects of CU and traumatic stress

on perceptions of a potential victim’s emotional state in an experimental context.

Hypothesis: Given literature documenting enhanced identification of fearful faces among

14

trauma-exposed youth (Masten et al., 2008), it was expected that traumatic stress would

moderate the effect of CU severity on ratings of the simulated opponent’s negative affect.

Specifically, it was predicted that higher levels of child traumatic stress would be

associated with a stronger link between CU and ratings of the simulated opponent’s

negative affect, such that greater traumatic stress was associated with higher ratings of

these emotions. It was also expected that child traumatic stress would moderate the effect

of CU severity on changes in ratings of the opponent’s negative affect, such that higher

levels of traumatic stress would be associated with a stronger link between CU and

changes in perceptions of opponents’ negative affect, given literature linking child

traumatic stress to enhanced identification of others’ fear-related cues (Masten et al.,

2008).

•Aim IVa: Elucidate the interactive effects of CU and anxiety on

parasympathetic-based regulation in response to others’ distress. Hypothesis: It was

expected that CU will be associated with blunted parasympathetic response to others'

distress similar to previous findings (e.g., Anastassiou-Hadjicharalambous & Warden,

2008b; de Wied et al., 2012), but that anxiety would alter this relationship by increasing

parasympathetic response to this stimulus, given that anxiety has been associated with

increased attention to distress cues among CU youth (Kimonis et al., 2012).

•Aim IVb: Elucidate the interactive effects of CU and traumatic stress on

parasympathetic response to others’ distress. Hypothesis: It was expected that traumatic

stress would alter the relationship between CU and blunted parasympathetic regulation by

increasing parasympathetic response to others’ distress, given that traumatic stress has

been associated with both increased attention to distress cues (e.g., Masten et al., 2008)—

15

an emotional processing pattern observed among CU youth (Kimonis et al., 2012)—and

heightened autonomic activity (Teicher et al., 2002).

Gaining a better understanding of the relationships between child anxiety,

traumatic stress, CU, and observed aggressive behavior in the context of experimentally

manipulated distress cue salience is critical to informing individualized treatment

strategies and offsetting future difficulties. As a whole, these efforts can contribute

valuable information to assessment and intervention science, reducing the heavy burden

that CU places on affected individuals, their families, and society at large.

II. METHODOLOGY

Participants and Recruitment

All study activities were approved by the Florida International University

Institutional Research Board. A conduct problems (CP)-enhanced community sample was

recruited, given the relatively low rate of CU in the general community (Rowe et al.,

2010). Specifically, community recruitment of youth included—in addition to broad

school-based and flyer-based recruitment—strategic recruitment outreach at clinics

offering behavioral treatments for child behavior problems. Phone screens were

administered to interested caregivers of potential participants to assess whether children

met the following eligibility criteria: 1) age of seven to thirteen years, inclusive; 2) no

reported history of autism spectrum disorder or severe mental or physical impairments

(e.g., intellectual disability, deafness, blindness); and 3) no current psychotropic

treatment, except for stimulant medications which could be easily discontinued for study

participation. Eligible families were invited to a laboratory visit to complete the

following: 1) informed consent and assent, 2) child laboratory tasks and rating scales, and

16

3) caregiver rating scales. Prior to the visit, families of children taking stimulant

medication were asked to forgo medication administration for a 48-hour washout period.

This period is considered sufficient to preclude stimulant medication effects on tasks

(Greenhill et al., 2001), and has been used in previous research on children’s cognitive

task performance (e.g., Wilson, Mitchell, Musser, Schmitt, & Nigg, 2011).

Participants were 45 children between the ages of seven and thirteen (M=9.89,

SD=1.58; 71.1% boys, 28.9% girls) and their caregivers. Caregivers (90.9% mothers,

6.8% fathers, 2.3% grandmothers) reported on child participants’ emotions and behavior,

as well as demographic information. Regarding race/ethnicity, per caregiver report,

75.6% of child participants were Hispanic, 13.3% were non-Hispanic White, and 11.1%

were non-Hispanic Black. Among families for whom income was reported, 50% of

caregivers reported an annual income of $48,000 or lower, 25% of caregivers reported an

income between $50,000 and $97,000, and 25% of caregivers reported an annual income

of $100,000 or higher. Children recruited from clinics showed no differences from

children recruited from other community sources with regard to gender (χ2(1)=0.65,

p=.42), race/ethnicity (χ2(2)=1.38, p=.50), age (t(43)=-0.33, p=74) and household income

(t(34)=0.13, p=.90).

Procedures and Measures

During the laboratory visit, informed consent and assent was obtained from

caregivers and child participants, respectively. Next, caregivers completed questionnaires

on children’s emotion and behavioral characteristics, while children participated in

several experimental tasks and completed self-report questionnaires. Two laboratory

tasks were used to measure child responses to others' distress, and task order was

17

counterbalanced to control for any potential task sequence effects. The order in which

the laboratory tasks were administered was chosen using a counterbalance sheet, such

that the task order was reversed from the preceding participating, allowing approximately

50% of children to participate in one task first, and 50% of children to participate in the

other task first. Following participation in the laboratory tasks, an intelligence test was

administered to child participants, and then children completed self-report questionnaires.

Lastly, children were de-briefed on the use of deception (as described below) in the

laboratory tasks. Caregivers were compensated with a $25 gift card, and children

received a toy, following completion of all study activities and measures.

Child callous-unemotional traits. Caregiver ratings on the Inventory of Callous

Unemotional Traits (ICU; Essau, Sasagawa, & Frick, 2006) were used to measure child

CU traits. The ICU is a well-established measure of CU traits in this age group, and is

comprised of 24 items rated on a scale from 0 (“Not at all true”) to 3 (“Definitely true”).

Using the original scoring, Kimonis, Fanti, and Singh (2014) found children with a

parent-rated ICU total score of 24 or above would benefit from services tailored towards

CU traits. Numerous studies support the reliability and validity of the ICU, particularly in

distinguishing between CP behaviors and CU (e.g., Fanti et al., 2009; Kimonis et al.,

2008; Kimonis et al., 2014; Roose et al., 2009). Hawes and colleagues (2014a) used

exploratory factor analysis to identify an alternative scoring method that improved the

psychometric properties of the measure. Total scores obtained using Hawes’ et al.’s

alternative scoring method were used in the present analyses. Internal consistency was

acceptable in the current sample (α=.81).

18

Child anxiety. Child anxiety was measured by caregiver ratings on the

Multidimensional Anxiety Scale for Children, Second Edition (MASC; March, Parker,

Sullivan, Stallings, & Conners, 1997; March, 2013). The MASC is comprised of 39 items

on a scale from 0 (“Never true about me”) to 3 (“Often true about me”). The MASC

assesses several domains of anxiety that are summed to yield a total anxiety score. The

test-retest reliability and predictive validity of the MASC have been demonstrated by past

research (e.g., Muris, Merckelbach, Ollendick, King, & Bogie, 2002; Wei et al., 2014).

Internal consistency was very strong in the current sample (α=.92).

Prior child trauma exposure and posttraumatic stress symptoms. In keeping

with previous studies exploring the role of anxiety in CU (e.g., Kimonis et al., 2012),

children completed a self-report measure of trauma exposure and corresponding

posttraumatic stress symptoms. The Child PTSD Symptom Scale (CPSS; Foa et al.,

2001) was used to measure child posttraumatic stress symptoms. First, children were

administered a preliminary trauma exposure questionnaire. A list of the following

potentially traumatic events was provided: a) anything really terrible or upsetting, like

being very sick or badly hurt; b) seen anyone die or badly hurt; c) been in a really bad

accident or fire where you could have died; d) been in anything like a really bad

hurricane, flood, or earthquake or had a tornado near where you lived; e) been robbed or

attacked; f) been touched on parts of your body that you really didn’t want to be touched;

g) been made to touch someone else in places that you didn’t want to; h) been hit over

and over or hurt very badly by someone; i) anything else that someone has done to you,

or made you do, that you didn’t like. Children were asked to select “Yes” or “No” if they

had experienced any of these events (regardless of which, or how many, events they had

19

experienced). If children selected “Yes,” they were asked to complete the CPSS. The

CPSS is composed of 17 symptom-severity items rated from 0 (“Not at all or only at one

time”) to 3 (“5 or more times a week/almost always”), and 7 impairment “Yes” or “No”

items. The symptom severity items comprise several subscales—including re-

experiencing, avoidance, and hyperarousal—that are summed to create a total score. The

test-retest reliability and construct validity of the CPSS have been demonstrated in past

research (Foa et al., 2001; Gillihan, Aderka, Conklin, Capaldi, & Foa, 2013; Nixon et al.,

2013). Internal consistency of the CPSS was very strong in the current sample for the

symptom-severity (α=.92) items.

Child distress-response. The distress-response task was designed to assess

parasympathetic nervous system (PNS) regulation of physiological arousal in response to

the distress of others. Respiratory sinus arrhythmia (RSA; the high-frequency component

of the heart-rate variability spectrum) is an indicator of PNS regulation of physiological

arousal (Hayano et al., 2001; Appelhans & Luecken, 2006). During the task, children

were seated in a comfortable chair and connected to psychophysiological equipment.

Specifically, heart rate was measured using EKG leads applied to the upper right clavicle

and lower left rib, as well as a grounding electrode on the lower right rib. Impedance

cardiography allowed assessment of RSA and respiration using four electrodes. One

electrode was applied over the clavicle close to the neck, and another electrode was

applied to the back of the neck in a corresponding location. Additionally, one electrode

was applied over the xiphoid process, with another electrode applied to a corresponding

location over the spine.

20

Child participants were told they would listen to two recordings, including one

recording of nature sounds, and one recording of another child who was very upset.

Initial recording occurred for five minutes, during which a relaxation soundtrack was

played, to establish a resting baseline. Immediately following the relaxation soundtrack

audio recording, a five-minute audio recording of a distressed child crying was played.

Data collection and analysis occurred through equipment and software from MindWare

Technologies, Ltd. (Gahanna, OH). Respiration and heart rate were used to calculate

heart-rate variability, from which RSA was assessed using spectral analysis. Lower

resting RSA and parasympathetic-based regulation in response to distress cues reflects

reduced parasympathetic activity, a response observed in CU youth in comparison to

youth with behavior problems and healthy controls (Anastassiou-Hadjicharalambous &

Warden, 2008b; de Wied et al., 2012) and ADHD youth with low prosocial behavior, a

proxy for CU traits (Musser, Galloway-Long, Frick, & Nigg, 2013), in comparison to

ADHD youth without low prosocial behavior. Given high correlations across RSAResting

epochs (rs=.68-.90) and RSADistressExposure epochs (r=.78-.90), RSAResting was calculated by

averaging RSA across the five 60-second epochs of data collection during the relaxation

phase, and RSADistressExposure was calculated by averaging RSA across the five 60-second

epochs of data collection during the distress phase. RSAReactivity was calculated by

subtracting RSADistressExposure from RSAResting.

Child aggression. Aggression assessment consisted of a game simulation task

(SuperBuilder) modeled after the FastKid! task developed by Thomaes and colleagues

(2008), and a well-validated protocol used in adults with psychopathy (Giancola &

Zeichner, 1995). The task was designed for the present study to offer a standardized and

21

observational assessment of aggression, as well as changes in aggression with respect to

experimentally manipulated distress cue salience. Participants were told they were going

to play a computer game against another child situated out of sight in a nearby room. In

reality, the experimenter controlled all events, and there was no real child opponent. Prior

to the game, children were told that the goal of the game was to press a specific keyboard

button very quickly to construct buildings at a faster rate than their “opponent”, and that

there are two rounds with several trials each. First- and third-round winners earned the

opportunity to send the opponent a text message. Second- and fourth-round winners

earned the opportunity to “blast” the opponent with white noise. The “opponent” was

rigged to win the first and third round. Figures 1 -3 present several screen shots from the

computer task.

Distress cue salience was manipulated within subjects, with participants receiving

a neutral text message from the competitor following the first round (i.e., “This game is

crazy fast! #JustDoIt” accompanied by a neutral emoticon), and a text message

expressing distress following the third round (i.e., “Super worried about that blast!”

accompanied by a sad emoticon). To ensure that child participants were able to read the

message received from their fictitious opponent, participating youth were asked to read

each message aloud immediately following receipt. Participants were rigged to win the

second and fourth round, were given an example of the noise they could use against their

opponent, with intensities ranging from no noise (level 0) to 100 dB (level 10; intensity

of a smoke alarm), and were told that levels 7 and above are extremely loud. Observed

aggression was measured by noise levels chosen; noise levels from round 2 represent

child aggression in the absence of a distress cue, noise levels from round 4 represent

22

aggression in the presence of a distress cue, and the sum of these noise levels represents

total observed aggression. Participants entered noise levels chosen using the keyboard,

and typed responses were recorded directly into a document. The first response typed was

considered the noise level chosen. Immediately following their entry, children were asked

to confirm the noise level they chosen; each child accurately related his or her typed

choice (r=1.00, p<.001).

Following each round of SuperBuilder, children were administered a peer

perception scale (PPS), in which they rated their perceptions of the intensity of emotions

(i.e., sad, scared, angry, calm, happy) experienced by the fictitious competitor on a scale

from 0 (“Not at all”) to 4 (“Extremely”).

Child intelligence. The Wechsler Abbreviated Scale of Intelligence, Second

Edition (WASI-II; Wechsler, 1999; 2011) was used to measure children’s intelligence.

While the instrument is comprised of four subtests—Block Design, Vocabulary, Matrix

Reasoning, and Similarities, a full-scale IQ (FSIQ2) may be calculated using the Matrix

Reasoning and Vocabulary subtests. The factor structure and validity of the WASI have

been supported (Canivez, Konold, Collins, & Wilson, 2009; Sakolfske, Caravan, &

Schwartz, 2000).

Analytic Plan

Means, SDs, and zero-order correlations among study variables were first

computed. A check was conducted examining the success of tasks’ manipulation of

others’ distress salience. Paired-samples t-tests were conducted examining differences

between the distress and no distress salience conditions with regard to participant reports

on the PPS of how “calm,” “happy,” “angry,” “sad,” and “scared” their opponent was.

23

Regression techniques were used to assess relationships between CU, anxiety, and

physiological, as well as behavioral, responses to others' distress. Prior to conducting the

main analyses, data were checked for normality and other assumptions of regression

models; given the skewed distribution of several study variables and sample size,

bootstrap estimations of population distributions were used to increase confidence in

results (Efron, 1979; Efron & Tibshirani, 1993). Bootstrapping resampling techniques

produce robust standard errors and confidence interval estimates when assumptions of

regression are not met (Bollen & Stine, 1990; Russel & Dean, 2000).

Hierarchical linear regression models were used to assess moderation for study

Aims I-III. Figure 4 depicts the analytical models examined to predict aggression,

changes in child ratings of peer emotions between the neutral and distress messages, and

parasympathetic responses to distress. Moderation analyses were conducted using the

PROCESS macro for SPSS (Hayes, 2012). For each model predicting behavioral or

parasympathetic response outcomes, the main effects of child CU traits and anxiety were

entered, as well as the product term of CU traits and anxiety; parallel models were

created by entering the main effects of child CU traits and traumatic stress, as well as the

product term of CU traits and traumatic stress. Significant moderation is defined by a

significant interaction (product) term of the predictor (CU traits) and proposed moderator

(anxiety or traumatic stress) after accounting for main effects (Baron & Kenny, 1986;

Holmbeck, 1997; Kendall & Comer, 2011). In bootstrapped regression, 95% bias-

corrected confidence intervals, rather than p-values, are used to assess significance;

specifically, the null hypothesis is rejected if zero does not fall within the confidence

interval (Rasmussen, 1987). Variables were mean-centered prior to entry in analyses.

24

Additional moderation analyses predicting parasympathetic responses further

examined whether clinical characteristics differentially predicted participants’

parasympathetic responses to others’ distress unfolding across time. Specifically,

hierarchical linear modeling (HLM) was used to examine whether CU, anxiety, traumatic

stress, and their interactions predicted changes in RSADistress across time during prolonged

exposure to others distress. Separate, parallel models predicting RSADistress across the 5

individual distress-condition epochs (i.e., RSADistress1 through RSADistress5) were created

for anxiety and traumatic stress moderators, such that time, CU, anxiety, and their

interactions were entered as predictors in one model, and time, CU, traumatic stress, and

their interactions were entered as predictors in a second model. RSAResting was entered as

a covariate in both models.

Missing values analyses found no significant differences among participants with

and without missing data on study variables, suggesting that data were missing

completely at random, χ2(168)=190.75, p=.11 (MCAR; Little & Rubin, 1987). Given the

random nature and small overall percentage (1.7%) of missing data, listwise deletion was

used to handle missing observations.

III. RESULTS

Table 1 presents descriptive data for study variables and participant

demographics. Nearly half (45.5%, N=20) of this CP-enhanced community sample

showed significant CU traits according to Kimonis and colleagues’ (2014) criteria (i.e.,

ICU > 24). Roughly 31% (N=14) of the sample showed anxiety in the high-average range

or above (i.e., MASC t score > 55), with approximately 20% (N=9) showing clinically

elevated anxiety (i.e., MASC t score > 60; March, 2013). With regard to trauma, 55.6%

25

(N=25) of the sample experienced a traumatic event; of these children, approximately

31% (N=14) met symptom severity criteria for PTSD (Foa et al., 2001; Hawkins &

Radcliffe, 2006).

Youth were fairly aggressive overall, with only 4.4% (N=2) of children choosing

not to aggress against their opponent at all following receipt of the neutral message, and

only 8.9% (N=4) choosing not to aggress against their opponent at all following receipt

of the distress message. Roughly 71% (N=32) of youth delivered a “blast” at level 7 or

above, which was explained to the participants as “extremely loud” during the game

instructions; this percentage remained the same following receipt of both neutral and

distress messages from the opponent. The number of children selecting the highest

blast—level 10—increased from 23 (approximately 51%) following receipt of a neutral

message to 27 (60%) following receipt of a distress message. Table 2 provides zero-order

correlations for main study variables.

Manipulation checks indicated the task was successful in manipulating the

salience of the opponent distress. A paired-samples t-tests manipulation check revealed

children’s ratings of how “scared” and “sad” they perceived their opponent to be indeed

increased from the no distress/neutral message condition to the distress salience condition

(t(43)=7.75, p<.001, t(43)=5.03, p<.001, respectively). Children’s ratings of how “angry”

they perceived their opponent to be also increased from the no distress/neutral message

condition to the distress salience condition (t(43)=5.90, p<.001). Similarly, children’s

ratings of how “calm” and “happy” they perceived their opponent to be decreased from

the no distress/neutral message condition to the distress salience condition (t(42)=-2.50,

p=.02, t(43)=-7.37, p<.001, respectively).

26

Addressing Aim Ia: Elucidating the interactive effects of CU and anxiety on

aggression

Table 3 presents results from hierarchical regression analyses examining the main

and interactive effects of CU traits and anxiety on total observed child aggression

exhibited during the SuperBuilder game. The overall model was significant in the

prediction of total aggression pooled across the two conditions, F(3, 40)=3.03, p=.04; R2

=0.18. However, neither CU traits nor anxiety significantly predicted total aggression

pooled across the two conditions. Similarly, the product term examining the interactive

effect between CU traits and anxiety did not significantly predict total aggression pooled

across the two conditions.

Addressing Aim Ib: Elucidating the interactive effects of CU and traumatic stress

on aggression

Table 4 presents results from hierarchical regression analyses examining the main

and interactive effects of CU traits and traumatic stress on total observed child aggression

exhibited during the SuperBuilder game. The overall model was not significant in the

prediction of aggression, with F(3, 19)=0.27, p=.85, R2 =0.05.

Addressing Aim IIa: Investigating the interactive effects of CU and anxiety on

aggression in the presence versus absence of distress cues

Table 3 also presents results from hierarchical regression analyses examining the

main and interactive effects of CU traits and anxiety on child aggression exhibited during

the SuperBuilder game, broken down by condition (i.e., presence versus absence of

others’ distress salience).

27

Observed aggression in the absence of a distress cue. The overall model was

significant, F(3, 40)=4.41, p=.01; R2 =0.34. Anxiety and CU traits each significantly

predicted aggression in this condition—explaining 16.2% and 6.5%, respectively, of the

variance in aggression in the absence of a distress cue. As a main effect, CU positively

predicted observed aggression, whereas anxiety as a main effect negatively predicted

observed aggression. In addition, the product term examining the interactive effect

between CU traits and anxiety contributed additional, unique predictive value (F(1,

40)=4.54, p=.04; R2Δ=0.12), indicating that the association between CU traits and

aggression in the absence of a distress cue was not uniform across varying levels of

anxiety.

Follow-up analyses examined simple slopes associated with high, medium, and

low levels of anxiety. High was defined as one standard deviation above the centered

mean anxiety total score, medium was defined as within one standard deviation of the

centered mean anxiety total score, and low was defined as one standard deviation below

the centered mean anxiety total score. Analyses revealed that CU traits were significantly

predictive of increased aggression in the absence of a distress cue among children with

medium and high levels of anxiety (β=0.16, SE=0.06, 95% CI=0.03-0.29 and β=0.37,

SE=0.14, 95% CI=0.10-0.65, respectively). In contrast, CU traits were not predictive of

increased aggression in the absence of a distress cue among children with low levels of

anxiety (β=-0.05, SE=0.09, 95% CI=-0.24-0.14). Figure 5 presents a graphical depiction

of the interactive relationship between CU and anxiety when predicting aggression in the

absence of a distress cue.

28

Observed aggression in the presence of a distress cue. The overall model was

not significant in the prediction of aggression in the presence of a distress cue, F(3,

40)=0.31, p=.82; R2 =0.04. Similarly, neither CU, anxiety, nor their interaction

significantly predicted observed aggression in the presence of a distress cue.

Addressing Aim IIb: Investigating the interactive effects of CU and traumatic stress

on aggression in the presence versus absence of distress cues

Table 4 also presents results from hierarchical regression analyses examining the

main and interactive effects of CU traits and traumatic stress on child aggression

exhibited during the SuperBuilder game, broken down by condition (i.e., presence versus

absence of others’ distress salience).

Aggression in the absence of a distress cue. The overall model was not

significant in the prediction of aggression, with F(3, 19)=0.36, p=.79, R2 =0.05.

Aggression in the presence of a distress cue. The overall model was not

significant in the prediction of aggression, with F(3, 19)=0.25, p=.86, R2 =0.04.

Addressing Aim IIIa: Elucidating the main and interactive effects of CU and anxiety

on perceptions of a potential victim’s emotional state in an experimental context

Tables 5 and 6 present results from hierarchical regression analyses examining the

main and interactive effects of CU traits and anxiety on child ratings of opponent

emotions in neutral and distress cue conditions (respectively) in the SuperBuilder game.

Ratings of opponent emotions in the absence of a distress cue. The overall

models were not significant in predicting child ratings of opponent “calm” (F(3, 38)=0.12

p=.95; R2 =0.01), “happy” (F(3, 39)=1.01, p=.40; R2 =0.06), “angry” (F(3, 39)=1.49,

29

p=.23; R2 =0.11), “sad” (F(3, 39)=0.77, p=.52; R2 =0.04), and “scared” (F(3, 39)=0.20,

p=.90; R2 =0.03) feelings.

Ratings of opponent emotions in the presence of a distress cue. The overall

models were not significant in predicting child ratings of opponent “calm” (F(3,

39)=1.89, p=.15; R2 =0.11), “happy” (F(3, 39)=2.04, p=.12; R2 =0.12), “angry” (F(3,

39)=2.17, p=.11; R2 =0.08), “sad” (F(3, 39)=0.07, p=.97; R2 =0.01), and “scared” (F(3,

39)=1.69, p=.19; R2 =0.09) feelings.

Change in ratings of opponent emotions between neutral- and distress-cue

conditions. Table 7 presents results from hierarchical regression analyses examining the

main and interactive effects of CU traits and anxiety on change in child ratings of

opponent emotions between neutral and distress cue conditions in the SuperBuilder game.

Overall models were not significant in predicting change in ratings of opponent “calm”

(F(3, 38)=1.59, p=.21; R2 =0.09), “scared” (F(3, 39)=0.79, p=.51; R2 =0.07), and “sad”

(F(3, 39)=0.05, p=.98, R2 =0.01) feelings. The overall model was significant in the

prediction of change in ratings of opponent “angry” feelings, F(3, 39)=3.49, p=.02; R2

=0.15. However, neither CU traits nor anxiety significantly predicted change in ratings of

opponent “angry” feelings between the two conditions. Similarly, the product term

examining the interactive effect between CU traits and anxiety did not significantly

predict change in ratings of opponent “angry” feelings between the two conditions. The

overall model was significant in the prediction of change in ratings of opponent “happy”

feelings was significant, F(3, 39)=3.73, p=.02; R2 =0.19. Neither anxiety nor its

interaction with CU traits significantly predicted change in ratings of opponent “happy”

feelings between the two conditions. However, CU traits were a significant negative

30

predictor in this model. Specifically, the greater the child’s CU severity, the less change

in ratings between the neutral- and distress-cue conditions.

Addressing Aim IIIb: Investigating the main and interactive effects of CU and

traumatic stress on perceptions of a potential victim’s emotional state in an

experimental context

Tables 8-9 present results from hierarchical regression analyses examining the

main and interactive effects of CU traits and traumatic stress on child ratings of opponent

emotions in neutral and distress cue conditions in the SuperBuilder game.

Ratings of opponent emotions in the absence of a distress cue. The overall

models were not significant in predicting child ratings of opponent “calm” (F(3,

17)=0.39, p=.76; R2 =0.07), “happy” (F(3, 18)=0.63, p=.61; R2 =0.09), “angry” (F(3,

18)=1.04, p=.40; R2 =0.20), “sad” (F(3, 18)=1.09, p=.38; R2 =0.13), and “scared” (F(3,

18)=0.36, p=.78; R2 =0.12) feelings.

Ratings of opponent emotions in the presence of a distress cue. The overall

models were not significant in predicting child ratings of opponent “happy” (F(3,

18)=1.07, p=.39; R2 =0.12), “angry” (F(3, 18)=0.41, p=.75; R2 =0.10), and “sad” (F(3,

18)=0.37, p=.77; R2 =0.07) feelings. The overall model was significant in the prediction

of ratings of opponent “scared” feelings, F(3, 18)=7.91, p=.001; R2 =0.36. Child CU was

a significant negative predictor, and child traumatic stress was a significant positive

predictor, of ratings of opponent “scared” feelings. Specifically, greater traumatic stress

was associated with higher ratings, and greater CU was associated with lower ratings, of

opponent “scared” feelings. The overall model was also significant in the prediction of

ratings of opponent “calm” feelings, F(3, 18)=4.18, p=.02; R2 =0.46. Child CU was a

31

significant positive predictor of ratings of opponent “calm” feelings. Specifically, greater

CU was associated with higher ratings of opponent “calm” feelings.

Change in ratings of opponent emotions between neutral- and distress-cue

conditions. Table 10 presents results from hierarchical regression analyses examining the

main and interactive effects of CU traits and traumatic stress on change in child ratings of

opponent emotions between neutral and distress cue conditions in the SuperBuilder game.

The overall models were not significant in predicting change in ratings of opponent

“calm” (F(3, 17)=0.87, p=.48; R2 =0.24), “happy” (F(3, 18)=1.95, p=.16; R2 =0.27),

“angry” (F(3, 18)=0.20, p=.90; R2 =0.03), and “sad” (F(3, 18)=0.23, p=.88; R2 =0.08)

feelings. The overall model was significant in the prediction of change in ratings of

opponent “scared” feelings, F(3, 18)=6.97, p=.003; R2 =0.28. However, neither CU traits

nor traumatic stress significantly predicted change in ratings of opponent “scared”

feelings between the two conditions. Similarly, the product term examining the

interactive effect between CU traits and traumatic stress did not significantly predict

change in ratings of opponent “scared” feelings between the two conditions.

Addressing Aim IVa: Elucidating the main and interactive effects of CU and anxiety

on parasympathetic response to others’ distress

Table 11 presents results from hierarchical regression analyses examining the

main and interactive effects of CU traits and anxiety on baseline parasympathetic

functioning (RSAResting) and on parasympathetic response exhibited during the Distress

Task (RSAReactivity). Models were not significant in the prediction of RSAResting, F(3,

39)=0.98, p=.41, R2 =0.09, nor in the prediction of RSAReactivity , F(3, 39)=0.75, p=.53, R2

=.03.

32

Table 12 presents results from HLM analyses examining the main and interactive

effects of CU, anxiety, and their interaction associated with minute-to-minute changes in

RSADistress across time. RSAResting, entered as a covariate, was a significant positive

predictor of RSADistress across time, and the interaction between time and child anxiety

was a significant negative predictor of RSADistress. Time, CU, anxiety, and the interactions

between Time and CU, and Time and the product term of CU and anxiety, were not

significant predictors of in RSADistress.

Follow-up analyses probing the significant AnxietyXTime interaction in the

prediction of RSADistress across time examined RSADistress across time among the

subgroups of youth with high versus low levels of anxiety. High anxiety was defined as

above the mean MASC total score, and low anxiety was defined as below the mean

MASC total score. Among youth with high anxiety, analyses indicated that RSAResting

(the covariate) and Time were significant predictors of RSADistress (B=0.99, SE=0.05,

t(120)=20.45, p<.001 and B=-0.09, SE=0.04, t(120)=-2.16, p=.03, respectively).

Specifically, among youth with higher anxiety, RSADistress declined in a linear fashion

from minute 1 through minute 5 during exposure to others’ distress. In contrast, among

youth with low anxiety, while RSAResting (the covariate) was a significant predictor of

RSADistress (B=0.90, SE=0.05, t(100)=18.83, p<.001), Time was not a significant predictor

(B=-0.004, SE=0.04, t(100)=-0.11, p=.91). That is, among youth with higher anxiety

severity, RSA patterns suggest progressive parasympathetic suppression across time

during exposure to others’ distress, whereas exposure to others distress is not associated

with progressive parasympathetic suppression across time in youth with lower anxiety

severity.

33

Figure 6 presents a graphical depiction of the relationships between anxiety and

RSADistress across time.

Addressing Aim IVb: Elucidating the interactive effects of CU and traumatic stress

on parasympathetic-based response to others’ distress

Table 13 presents results from hierarchical regression analyses examining the

main and interactive effects of CU traits and traumatic stress on baseline parasympathetic

functioning (RSAResting) and on parasympathetic response exhibited during the Distress

Task (RSAReactivity). Models were not significant in the prediction of RSAResting F(3,

19)=0.38, p=.77, R2 =0.03, nor in the prediction of RSAReactivity, F(3, 19)=0.71, p=.56, R2

=.05.

Table 14 presents results from HLM analyses examining the main and interactive

effects of CU, anxiety, and their interaction associated with minute-to-minute changes in

RSADistress across time. Time, CU, traumatic stress, and their interactions were not

significant predictors of RSADistress changes across time.

IV. DISCUSSION

Overview

The present study examined complex relationships between youth CU traits,

observed aggression, anxiety, trauma, perceptions of others’ emotions, and physiological

and behavioral responses to other’s distress. Overall, these results derived from

observational child aggression data are consistent with previous research that has only

utilized questionnaire-based data on child aggression (e.g., Fanti et al., 2013; Humayun et

al., 2013; Rosan et al., 2015) in suggesting that CU traits are associated with greater

aggression in the presence of higher levels of anxiety, and further clarify specific

34

conditions under which this relationship applies. Specifically, the present findings

obtained with an experimental paradigm indicate that anxiety moderates the effect of CU

on child aggression, but only in the absence of salient distress cues from a potential

victim. These findings extend research suggesting that children with CU traits and

anxiety are more aggressive than children with elevated CU but not anxiety, as well as

children low on both CU traits and anxiety (Fanti et al., 2013; Kahn et al., 2012).

Collectively, findings have both theoretical implications for CU traits as a construct, and

clinical relevance in the prevention and situational attenuation of aggression.

Aggression

The present work also adds to an increasing body of research documenting a

strong relationship between CU traits and aggression (e.g., Fanti et al., 2009;

Waschbusch et al., 2004), given that CU traits—and not just their interaction with

anxiety—positively predicted observed aggression towards the opponent when the

opponent’s distress was not apparent. Results further supported the findings of van

Baardewijk and colleagues (2009), who observed in a similar task that the relationship

between CU traits and aggression changes when distress is made salient; however, the

present study was the first to consider the role of anxiety in this relationship.

Theoretical distinctions between children with CU traits and anxiety versus

children with CU traits but no anxiety are supported by the observed interaction. It

appears that anxiety provides useful predictive information on the clinical presentation of

CU traits, particularly in ambiguous social situations during which potential victims’

distress is unclear. Interestingly, although anxiety by itself predicted reduced aggression

under such ambiguous circumstances, anxiety actually sensitized youth with CU to

35

aggress more than seen in CU youth without anxiety. It is possible that the increased

attention to distress cues noted among CU youth experiencing anxiety represents a

sensitivity to negative emotional cues in general, similar to the attentional biases towards

negative- and threat-related cues (Mogg & Bradley, 2005; Reid et al., 2006), and bias

towards interpreting ambiguous information negatively (Taghavi et al., 2000)

documented among anxious children. While CU traits have not previously been

associated with a hostile attribution bias (HAB; Dodge, Price, Bachorowski, & Newman,

1990; Frick et al., 2003a; Helseth, Waschbusch, King, & Willoughby, 2015), perhaps the

combination of cognitive biases associated with anxiety and the callousness of CU traits

yields the impulsive, aggressive reactivity documented in these youth (e.g., Fanti et al.,

2013; Kahn et al., 2013).

Perceptions of Peer Emotions

Indeed, it appears that CU traits are associated with difficulty understanding

others’ emotions, even when distress is made apparent. Youth CU traits were associated

with lower ratings of opponent fear and higher ratings of calm in the presence of a

distress cue from the opponent, as well as less change in participant ratings of perceived

opponent happiness from the neutral to distress message during the SuperBuilder task.

These findings support previous literature documenting that increased distress cue

salience reduces—but does not eliminate—emotion recognition deficits associated with

CU, as well as a tendency for CU youth to minimize victim distress resulting from

aggression (Pardini & Byrd, 2012). Importantly, in the present experimental study,

distress was salient enough to reduce the impact of CU on observed aggressive behavior,

regardless of perceived opponent emotion. The reduced impact of CU on aggression,

36

regardless of perceived emotion of the opponent, suggests the potential for effecting

change on a behavioral level relatively quickly, by increasing the “visibility” of a

potential victim’s distress—while supporting long-term reductions in aggressive behavior

through training to not only recognize, but also anticipate, others’ distress and respond

with prosocial behavior.

Physiological Responses

With regard to physiological responses to others’ distress, findings did not support

the hypothesized interactive relationship between CU and anxiety in predicting resting

RSA and RSA reactivity. The lack of effects was in contrast to the results of previous

studies showing that CU traits are associated with blunted parasympathetic activity at rest

(e.g., de Wied et al., 2012) and in response to threat and distress cues (e.g., Anastassiou-

Hadjicharalambous & Warden, 2008b). Given the relatively small sample size of the

present study, and the relatively small nature of psychohysiological effects in studies

comparing CNS activity of youth with and without CU traits (e.g., Anastassiou-

Hadjicharalambous & Warden, 2008b; de Wied et al., 2012; Musser et al. 2013), power

to detect moderation effects may have been compromised. Interestingly, anxious youth

showed greater parasympathetic suppression across time with extended exposure to

another child’s distress; the same was not true of non-anxious children. Existing literature

indicates that high RSA reactivity in response to distressing stimuli may be a biomarker

of reduced emotion regulation capabilities (Beauchaine, 2015). While sample size may

have precluded detection of effects related to CU and its interaction with anxiety across

time (as suggested by the trending effects noted in Table 9), findings related to anxiety

and RSA reactivity over time hint that the specific parasympathetic response pattern

37

associated with anxiety may explain anxiety-related heterogeneity in aggressive behavior

among CU youth. As research both specific to CU traits and on empathy in general

suggests that blunted parasympathetic and sympathetic activity may be partially

responsible for deficits in empathy-related responding, rather than solely the failure to

detect and understand emotional cues (e.g., Blair et al., 2006; Shirtcliff et al., 2009),

further investigation is needed to identify whether physiological responses contribute to

anxiety-related heterogeneity among CU youth—particularly given the increased

attention to distress cues observed in CU youth experiencing anxiety symptoms (Kimonis

et al., 2012). Future studies would do well to investigate specific profiles of

parasympathetic response to others’ distress across time in larger samples.

Trauma-related Findings

Statistical power may also have interfered with detection of trauma-related

moderation effects, as traumatic stress data were available only for the part of the sample

that experienced a traumatic event (N=25). However, among these youth, traumatic stress

symptom severity still predicted increased ratings of opponent fear in the presence of a

distress cue, in line with literature documenting enhanced identification of fear-related

cues among trauma-exposed youth (e.g., Masten et al., 2008). Child CU traits were also

positively correlated with traumatic stress—but not anxiety—indicating a potential

relationship between CU and traumatic stress that is not accounted for by trauma-related

anxiety. The high rate of trauma exposure in this CP-enhanced community sample sheds

light on the overall need to understand potential trauma responses—particularly given

evidence that traumatic stress influences perceptions of others’ fear—and the observed

38

correlation between CU traits and traumatic stress suggests the need for further

exploration of how these constructs co-occur in trauma-exposed youth.

Clinical Implications

Important clinical and practical implications follow from study findings as a

whole. Children with CU traits may benefit from training to anticipate situations that may

cause others’ distress, to attend to, and accurately identify, distress cues (and cues to the

potential for distress) and to alter behavior accordingly with contingency management

and prosocial behavior training. Given that high anxiety levels increase the likelihood for

aggression in the absence of salient distress cues (and the presence of neutral, ambiguous

cues), identifying children with high levels of CU traits and anxiety for emotional

training-based intervention may be particularly important. In potentially aggressive

situations involving children with CU traits, increasing the salience of others’ distress

cues (and/or potential for distress) may attenuate aggressive outcomes. Interestingly, the

widely encouraged practice of ignoring, or remaining confident/neutral when facing

aggression and provocation may not apply to victims of aggressors with CU—and

especially aggressors with CU and anxiety. In these situations, it may be best for victims

to make their distress salient to the aggressor in order to reduce aggression.

Limitations

Conclusions should be interpreted in light of several study limitations. The first

set of limitations relates to the nature of the study sample. The sample size may have

yielded inadequate statistical power to detect small-to-medium effects, particularly low-

magnitude psychophysiological effects, and trauma-related effects that were, by

necessity, examined in an even smaller participant subset. Sample size precluded

39

investigation of the relationships of interest while controlling for demographic factors

relevant to aggression, such as age and gender (Baillargeon et al., 2007; Costello,

Mustillo, Erklani, & Angold, 2003; Loeber & Hay, 1997). Future research would do well

to investigate physiological responses—including indices of both parasympathetic and

sympathetic activity, given research indicating blunted parasympathetic and sympathetic

responses in CU youth (e.g., Blair et al., 1999; de Wied et al., 2012)—to others’ distress

in larger samples, as well as the potential role of trauma in differences between CU youth

with and without anxiety in a trauma-exposed sample. In addition, the CP-enhanced

sample yielded data that did not conform to normality standards for typical linear

regression analyses. While bootstrapping techniques allowed for correction and increased

confidence in results, future research should investigate relationships in larger clinical

samples, so that statistical techniques geared towards analyzing skewed data (e.g.,

Poisson regression) may be used. Relatedly, as CU traits are typically conceptualized in

the context of child behavior problems, conducting further study in a clinical sample

would allow more in-depth analysis of the CU construct. However, the practice of

blending community recruitment with recruitment of youth with serious behavior

problems in order to yield a CP-enhanced sample is not unprecedented in the CU and

anxiety literature (e.g., Docherty et al., 2015). Third, the sample included mostly

Hispanic youth, with few African American children and few non-Hispanic Caucasian

children. Although this sample is fairly representative of the ethnic demographics of the

city in which data were collected (70% Hispanic, 11.9% White non-Hispanic, 16.3%

Black or African American non-Hispanic; U.S. Census Bureau, 2010), results may not

generalize to other populations and cultures.

40

A second set of limitations relates to the nature of data collected, including

measures in the SuperBuilder task and information on traumatic exposure. Although data

were collected on child perception of peer emotions, data were not collected on child

perception of peer intentions, precluding the assessment of interpretive biases and social

goals during the SuperBuilder task. Given the reactive profile of children with CU and

anxiety (e.g., Fanti et al., 2013), and the potential for interactive social-cognitive biases

associated with both CU (e.g., Pardini, 2011) and anxiety (e.g., Taghavi et al., 2000),

future research would do well to assess the role of cognition more extensively. Moreover,

children displayed relatively high aggression overall during the SuperBuilder task,

reducing the variability of aggression that could be predicted. Perhaps the aggression task

evoked competitive behavior that interfered with the emotional matching theorized to

underlie empathy (Eisenberg & Eggum, 2009), as observed in adult research (e.g.,

Cikara, Bruneau, & Saxe, 2011; Weyers, Mühleberger, Kund, Hess, & Pauli, 2009). With

regard to traumatic exposure, information on exposure to specific trauma types

experienced (e.g., physical abuse, witnessing community violence, natural disaster

exposure) was not collected. As a result, it was not possible to examine how trauma-

related findings may vary across various forms of traumatic exposure. Given previous

investigations indicating more extensive trauma histories among CU youth with anxiety

in comparison to their non-anxious counterparts (e.g., Humayun et al., 2015; Kimonis et

al., 2012), and research suggesting that emotional numbing symptoms link violence

exposure and delinquency (Allwood et al., 2011), it is possible that specific forms of

traumatic exposure (e.g., violence exposure) are more strongly associated with aggression

and aspects of emotional processing among youth with CU traits than other forms of

41

traumatic exposure (e.g., exposure to a natural disaster). Future studies would do well to

collect information on youths' exposure to specific forms of trauma.

A final limitation relates to study time period. Given the short-term nature of the

laboratory-based task, long-term conclusions cannot be drawn. Similarly, long-term

predictions of behavior and outcomes cannot be made, given the absence of longitudinal

follow-up data. While practice effects may preclude the administration of the

SuperBuilder task as-is at regular intervals, perhaps further task development and

sophistication (e.g., randomization of task conditions) would allow for more long-term

comparison. Longitudinal reports and records-based (e.g., school disciplinary records)

data would allow future researchers to examine the long-term predictive value of

observed responses to others’ distress among children with CU and anxiety.

Future Directions

In addition to the specific considerations for future research noted above, further

investigation is needed in general to identify potential mechanisms by which CU and

anxiety symptoms interact to increase aggression in the absence of distress cues. While

study findings suggest that emotional processing plays a role in this relationship, research

may do well to assess whether increases and decreases in aggression under these

conditions are mediated by physiological responses, social cognitive processes (such as a

HAB or perceptions of dominance), or both.

Summary and Conclusions

Despite the limitations noted above, the present study was the first to examine

relationships between CU traits, anxiety, and observed aggression in an experimental task

allowing manipulation of distress cue salience, and the first to examine relationships

42

between CU traits, anxiety, and parasympathetic responses to others’ distress. Findings

extend existing research by highlighting the role of emotional cues in the observed

aggressive responses of children with CU traits, particularly CU youth experiencing

anxiety symptoms. Although previous research has equated CU traits with a lack of

anxiety (see Frick & White, 2008), the present study joins a growing body of work

indicating that these two constructs are not mutually exclusive, but rather may interact to

predict some of the most concerning outcomes. The distinction between subset of

children with CU traits with and without anxiety appears to have significant clinical and

theoretical utility in predicting the heterogeneity of behavior among youth with CU traits,

as well as pointing to potential treatment targets; future research must further investigate

the nature of emotional processing deficits, and their role in the development of AB,

among children with CU traits and anxiety.

43

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54

APPENDICES

55

Figure 1. Excerpts from the SuperBuilder game play simulation. Participants were told

they were building the red brick skyscraper, while their opponent was building the yellow

skyscraper.

56

Figure 2. Explanation of SuperBuilder sound blast levels presented to the child

participant.

57

Figure 3. Neutral and distress messages, respectively, sent from the SuperBuilder

simulated opponent to the child participant.

58

Table 1. Descriptive statistics

M SD Range

Child Age 9.89 1.58 7-13

Family Income 72.19 49.60 17-200

Child FSIQ 107.70 13.42 64-132

RSABaseline 6.65 1.23 3.67-8.92

RSADistressExposure 6.74 1.24 3.51-9.06

RSADistress1 6.83 1.32 2.89-9.33

RSADistress2 6.83 1.34 3.60-9.37

RSADistress3 6.72 1.31 3.63-9.07

RSADistress4 6.69 1.34 3.16-9.09

RSADistress5 6.65 1.29 3.67-9.18

RSAReactivity -0.09 0.42 -0.89-0.90

MASC 46.96 18.30 10-91

ICU 8.34 5.45 0-19

Aggression—Distress Cue Absent 8.00 2.81 0-10

Aggression—Distress Cue Salient 7.71 3.40 0-10

Aggression—Total 15.71 5.40 0-20

CPSS 18.87 12.32 1-51

Note: SD=Standard Deviation;RSA=respiratory sinus arrhythmia; RSAReactivity=

RSABaseline minus RSADistressExposure; MASC=caregiver-reported child anxiety;

ICU=caregiver-reported child CU traits; CPSS=child-reported traumatic stress. Family

Income is in thousands of dollars.

59

Table 2. Zero-order correlations between study variables.

1 2 3 4 5 6 7 8 9 10 11 12 13

1. Age -

2. Gender -.01 -

3. Ethnicity .08 .07 -

4. Income -.21 .13 -.33* -

5. RSABaseline -.03 .30 -.01 -.25 -

6. RSADistressExposure .09 .23 .06 -.34* .94** -

7. RSAReactivity .19 .17 -.19 .30 .13 -.21 -

8. MASC .10 -.20 -.17 .21 -.23 -.26 .08 -

9. ICU .15 .05 .20 -.25 .05 .03 .08 -.11 -

10. AggressionNeutral -.31* .04 .05 -.18 .23 .23 -.01 -.37* .32* -

11. AggressionDistress -.39** -.07 .04 .003 -.05 -.07 .05 -.09 .13 .51** -

12. AggressionTotal -.42** -.03 .05 -.10 .09 .08 .03 -.25 .25 .84** .89** -

13. FSIQ -.07 .16 -.24 .39* .01 -.02 .10 .02 -.32* -.25 -.11 -.19

14. CPSS .05 .13 .002 -.18 .04 -.03 .23 -.28 .43* .11 .11 .12 -.32

60

Table 3. Coefficients for the SuperBuilder hierarchical regression models predicting

Aggression, with Anxiety as a moderator

Predicting Aggression—Distress Cue Absent

β SE LLCI ULCI

MASC -0.065 0.024 -0.113 -0.016

ICU 0.162 0.064 0.033 0.291

MASC x ICU 0.011 0.005 0.001 0.022

Predicting Aggression—Distress Cue Present

β SE LLCI ULCI

MASC -0.020 0.039 -0.098 0.058

ICU 0.081 0.105 -0.131 0.294

MASC x ICU 0.006 0.009 -0.012 0.024

Predicting Aggression—Total

β SE LLCI ULCI

MASC -0.085 0.048 -0.182 0.013

ICU 0.244 0.148 -0.056 0.543

MASC x ICU 0.017 0.011 -0.006 0.039

Note: β=Beta coefficient; SE=standard error; LLCI=lower limit of 95% confidence

interval; ULCI=upper limit of 95% confidence interval; MASC=caregiver-rated total

anxiety; ICU=caregiver-rated total CU traits. MASC x ICU = interaction between

caregiver-rated total anxiety and total CU traits.

61

Table 4. Coefficients for the SuperBuilder hierarchical regression models predicting

Aggression, with traumatic stress as a moderator

Predicting Aggression—Distress Cue Absent

β SE LLCI ULCI

CPSS 0.0001 0.059 -0.124 0.124

ICU 0.099 0.137 -0.187 0.385

CPSS x ICU 0.001 0.010 -0.020 0.022

Predicting Aggression—Distress Cue Present

β SE LLCI ULCI

CPSS 0.019 0.074 -0.136 0.173

ICU 0.085 0.164 -0.259 0.429

CPSS x ICU -0.005 0.016 -0.039 0.028

Predicting Aggression—Total

β SE LLCI ULCI

CPSS 0.019 0.124 -0.240 0.277

ICU 0.184 0.271 -0.383 0.752

CPSS x ICU -0.004 0.024 -0.054 0.046


interval; ULCI=upper limit of 95% confidence interval; CPSS=child-rated total traumatic

stress; ICU=caregiver-rated total CU traits. CPSS x ICU = interaction between child-

rated total traumatic stress and total CU traits.

62

Table 5. Coefficients for the hierarchical regression models perceptions of simulated

opponent’s emotions in the absence of a distress cue, with anxiety as a moderator

Predicting “Calm” Ratings—Distress Cue Absent

β SE LLCI ULCI

MASC -0.001 0.010 -0.021 0.020

ICU -0.018 0.031 -0.081 0.044

MASC x ICU 0.0002 0.001 -0.003 0.003

Predicting “Happy” Ratings—Distress Cue Absent

β SE LLCI ULCI

MASC -0.006 0.010 -0.027 0.016

ICU -0.043 0.030 -0.104 0.018

MASC x ICU -0.001 0.002 -0.005 0.003

Predicting “Angry” Ratings—Distress Cue Absent

β SE LLCI ULCI

MASC 0.013 0.008 -0.002 0.029

ICU 0.027 0.032 -0.038 0.092

MASC x ICU -0.001 0.002 -0.005 0.002

Predicting “Sad” Ratings—Distress Cue Absent

β SE LLCI ULCI

MASC 0.007 0.008 -0.010 0.023

ICU 0.001 0.026 -0.052 0.054

MASC x ICU -0.002 0.002 -0.006 0.001

63

Predicting “Scared” Ratings—Distress Cue Absent

β SE LLCI ULCI

MASC 0.006 0.010 -0.014 0.026

ICU 0.015 0.035 -0.057 0.087

MASC x ICU 0.001 0.002 -0.004 0.005





64


opponent’s emotions in the presence of a distress cue, with anxiety as a moderator

Predicting “Calm” Ratings—Distress Cue Present

β SE LLCI ULCI

MASC 0.009 0.013 -0.016 0.035

ICU 0.070 0.033 0.004 0.137

MASC x ICU 0.001 0.003 -0.004 0.006

Predicting “Happy” Ratings—Distress Cue Present

β SE LLCI ULCI

MASC 0.008 0.010 -0.012 0.027

ICU 0.069 0.030 0.009 0.130

MASC x ICU 0.0004 0.002 -0.003 0.004

Predicting “Angry” Ratings—Distress Cue Present

β SE LLCI ULCI

MASC -0.010 0.012 -0.035 0.015

ICU -0.039 0.042 -0.124 0.047

MASC x ICU -0.003 0.002 -0.008 0.001

Predicting “Sad” Ratings—Distress Cue Present

β SE LLCI ULCI

MASC 0.006 0.015 -0.024 0.037

ICU 0.009 0.047 -0.086 0.103

MASC x ICU -0.001 0.004 -0.008 0.007

65

Predicting “Scared” Ratings—Distress Cue Present

β SE LLCI ULCI

MASC -0.0003 0.014 -0.029 0.029

ICU -0.064 0.030 -0.125 -0.003

MASC x ICU 0.001 0.003 -0.005 0.007





66

Table 7. Coefficients for the hierarchical regression models predicting changes in

perceptions of simulated opponent’s emotions, with anxiety as a moderator

Predicting Change in “Calm” Ratings

β SE LLCI ULCI

MASC -0.010 0.016 -0.042 0.022

ICU -0.088 0.052 -0.192 0.017

MASC x ICU -0.001 0.003 -0.007 0.005

Predicting Change in “Happy” Ratings

β SE LLCI ULCI

MASC -0.013 0.012 -0.037 0.011

ICU -0.112 0.037 -0.188 -

0.037

MASC x ICU -0.001 0.002 -0.005 0.003

Predicting Change in “Angry” Ratings

β SE LLCI ULCI

MASC 0.024 0.014 -0.005 0.052

ICU 0.066 0.037 -0.009 0.142

MASC x ICU 0.002 0.002 -0.003 0.007

Predicting Change in “Sad” Ratings

β SE LLCI ULCI

MASC 0.0002 0.018 -0.035 0.036

ICU -0.008 0.052 -0.112 0.097

MASC x ICU -0.001 0.005 -0.011 0.008

67

Predicting Change in “Scared” Ratings

β SE LLCI ULCI

MASC 0.007 0.019 -0.031 0.044

ICU 0.079 0.054 -0.031 0.189

MASC x ICU -0.0003 0.004 -0.008 0.007





68


opponent’s emotions in the absence of a distress cue, with traumatic stress as a moderator

Predicting “Calm” Ratings—Distress Cue Absent

β SE LLCI ULCI

CPSS -0.017 0.032 -0.084 0.050

ICU 0.043 0.072 -0.109 0.194

CPSS x ICU -0.001 0.006 -0.014 0.011

Predicting “Happy” Ratings—Distress Cue Absent

β SE LLCI ULCI

CPSS 0.014 0.026 -0.041 0.067

ICU -0.059 0.065 -0.196 0.078

CPSS x ICU 0.002 0.008 -0.015 0.018

Predicting “Angry” Ratings—Distress Cue Absent

β SE LLCI ULCI

CPSS 0.020 0.038 -0.060 0.100

ICU 0.043 0.071 -0.106 0.193

CPSS x ICU 0.002 0.013 -0.026 0.030

Predicting “Sad” Ratings—Distress Cue Absent

β SE LLCI ULCI

CPSS 0.027 .027 0.332 -0.030

ICU -0.005 0.050 0.929 -0.110

CPSS x ICU -0.003 0.008 0.735 -0.019

69

Predicting “Scared” Ratings—Distress Cue Absent

β SE LLCI ULCI

CPSS -0.007 0.033 0.846 -0.077

ICU 0.063 0.073 0.404 -0.091

CPSS x ICU 0.003 0.012 0.803 -0.022


interval; ULCI=upper limit of 95% confidence interval; CPSS=child-rated total anxiety;

ICU=caregiver-rated total CU traits. CPSS x ICU = interaction between child-rated total

traumatic stress and caregiver-rated total CU traits.

70


opponent’s emotions in the presence of a distress cue, with traumatic stress as a

moderator

Predicting “Calm” Ratings—Distress Cue Present

β SE LLCI ULCI

CPSS -0.058 0.030 -0.121 0.006

ICU 0.165 0.048 0.064 0.266

CPSS x ICU 0.009 0.005 -0.002 0.019

Predicting “Happy” Ratings—Distress Cue Present

β SE LLCI ULCI

CPSS 0.003 0.028 -0.056 0.062

ICU 0.069 0.057 -0.050 0.189

CPSS x ICU -0.001 0.005 -0.011 0.009

Predicting “Angry” Ratings—Distress Cue Present

β SE LLCI ULCI

CPSS 0.034 0.031 -0.031 0.010

ICU -0.005 0.075 -0.161 0.152

CPSS x ICU 0.002 0.008 -0.016 0.019

Predicting “Sad” Ratings—Distress Cue Present

β SE LLCI ULCI

CPSS 0.012 0.038 -0.067 0.091

ICU 0.023 0.086 -0.158 0.203

CPSS x ICU 0.005 0.0007 -0.010 0.019

71

Predicting “Scared” Ratings—Distress Cue Present

β SE LLCI ULCI

CPSS 0.073 0.023 0.024 0.121

ICU -0.136 0.056 -0.254 -0.018

CPSS x ICU -0.005 0.007 -0.020 0.011


interval; ULCI=upper limit of 95% confidence interval; CPSS=child-rated total anxiety;

ICU=caregiver-rated total CU traits. CPSS x ICU = interaction between child-rated total

traumatic stress and caregiver-rated total CU traits.

72

Table 10. Coefficients for the hierarchical regression models predicting changes in

perceptions of simulated opponent’s emotions, with traumatic stress as a moderator

Predicting Change in “Calm” Ratings

Β SE LLCI ULCI

CPSS 0.049 0.039 -0.033 0.131

ICU -0.144 0.103 -0.362 0.074

CPSS x ICU -0.010 0.010 -0.031 0.012

Predicting Change in “Happy” Ratings

β SE LLCI ULCI

CPSS 0.010 0.025 0.064 -0.043

ICU -0.128 0.064 -0.263 0.006

CPSS x ICU 0.003 0.006 -0.010 0.016

Predicting Change in “Angry” Ratings

β SE LLCI ULCI

CPSS -0.014 0.035 -0.088 0.059

ICU 0.048 0.066 -0.090 0.186

CPSS x ICU 0.001 0.008 -0.016 0.017

Predicting Change in “Sad” Ratings

β SE LLCI ULCI

CPSS 0.015 0.048 -0.087 0.116

ICU -0.027 0.107 -0.252 0.198

CPSS x ICU -0.007 0.012 -0.033 0.019

73

Predicting Change in “Scared” Ratings

β SE LLCI ULCI

CPSS -0.079 0.052 0.030 -0.189

ICU 0.199 0.116 -0.045 0.442

CPSS x ICU 0.008 0.019 -0.033 0.048


interval; ULCI=upper limit of 95% confidence interval; CPSS=child-rated traumatic

stress; ICU=caregiver-rated total CU traits; CPSS x ICU= interaction between child-rated

total traumatic stress and caregiver-rated total CU traits.

74

Table 11. Coefficients for hierarchical regression models predicting parasympathetic

responses, with anxiety as a moderator

Predicting RSAResting

β SE LLCI ULCI

MASC -0.019 0.012 -0.044 0.007

ICU 0.010 0.037 -0.065 0.085

MASC x ICU 0.003 0.003 -0.003 0.009

Predicting RSAReactivity

β SE LLCI ULCI

MASC 0.003 0.004 -0.006 0.011

ICU 0.006 0.010 -0.014 0.026

MASC x ICU -0.001 0.001 -0.002 0.001

Note: Note: β=Beta coefficient; SE=standard error; LLCI=lower limit of 95% confidence


anxiety; ICU=caregiver-rated total CU traits; MASC x ICU = interaction between

caregiver-rated total anxiety and total CU traits; RSA = respiratory sinus arrhythmia.

75

Table 12. Coefficients for HLM predicting RSADistress scores across time, with CU and

anxiety as moderators

RSADistress

B SE t(215) p

RSAResting 0.936 0.035 27.064 <.001

Time -0.046 0.029 -1.605 .110

MASC 0.006 0.005 1.194 .234

ICU 0.021 0.018 1.186 .237

Time x ICU -0.009 0.005 -1.676 .095

Time x MASC -0.003 0.002 -2.138 .034

Time x ICUxMASC 0.0003 0.0001 1.793 .074

Note: Note: B=coefficient estimate; SE=standard error; MASC=caregiver-rated anxiety;

ICU=caregiver-rated total CU traits; MASC x ICU= interaction between caregiver-rated

total anxiety and caregiver-rated total CU traits; Time x ICUxMASC=interaction between

time and the product term of caregiver-rated total anxiety and caregiver-rated total CU

traits; RSA = respiratory sinus arrhythmia.

76

Table 13. Coefficients for hierarchical regression models predicting parasympathetic

responses, with traumatic stress as a moderator

RSAResting

β SE LLCI ULCI

CPSS 0.015 0.025 -0.039 0.068

ICU -0.036 0.068 -0.179 0.107

CPSS x ICU -0.003 0.005 -0.014 0.008

RSAReactivity

β SE LLCI ULCI

CPSS 0.008 0.012 -0.017 0.032

ICU 0.001 0.023 -0.047 0.048

CPSS x ICU <.001 0.002 -0.004 0.004



stress; ICU=caregiver-rated total CU traits; CPSS x ICU= interaction between child-rated

total traumatic stress and caregiver-rated total CU traits; RSA = respiratory sinus

arrhythmia.

77

Table 14. Coefficients for HLM predicting RSADistress across time, with CU and

traumatic stress as moderators

Predicting RSADistress

B SE t(115) p

RSAResting 0.867 .037 23.196 <.001

Time -0.043 0.037 -1.178 .241

CPSS 0.009 0.011 0.863 .390

ICU -0.011 0.024 -0.447 .656

Time x ICU 0.001 0.007 0.134 .893

Time x CPSS -0.004 0.003 -1.320 .189

Time x ICUxCPSS -0.0004 0.0003 -1.414 .160



stress; ICU=caregiver-rated total CU traits; CPSS x ICU= child-rated total traumatic

stress and interaction between caregiver-rated total CU traits; Time x

ICUxCPSS=interaction between time and product term of caregiver-rated total CU traits

and child-rated total traumatic stress; RSA=respiratory sinus arrhythmia.

78

Aim I/b.

Aim II/b.

Aim III/b.

Figure 4. Visual depiction of statistical models.

CU Traits Aggression

Anxiety/Traumatic Stress

CU Traits Aggression without Salient Distress Cue/

PPS Ratings/Change in PPS Ratings


CU Traits Aggression with Salient Distress Cue/

PPS Ratings/Change in PPS Ratings


CU Traits Parasympathetic Regulation


79

Figure 5. Graph depicting the interactive relationship between CU and anxiety when

predicting aggression in the absence of a distress cue.

0

2

4

6

8

10

12

ICU Low ICU Med ICU High

MASC Low MASC Med MASC High

Aggre

ssio

n—

Dis

tres

sC

ue

80

Figure 6. Graph depicting the relationships between respiratory sinus arrhythmia and

caregiver-reported child anxiety scores on the MASC across the five distress-condition

epochs in the Distress Response task.

6.2

6.4

6.6

6.8

7

7.2

7.4

0 1 2 3 4 5 6

High Anxiety Low Anxiety

RS

AD

istr

ess

Distress-Condition

81

VITA

KATHLEEN ISABEL CRUM

2005-2009 B.A., Psychology, Honors College, Summa Cum Laude

Florida International University

Miami, Florida

2009 National Institute of Health Travel Award

2010-2014 M.S., Psychology


Miami, Florida

2010-2016 Graduate Assistant


Miami, Florida

2013 & 2014 Award for Distinguished Poster Contribution

2014 Elizabeth Munsterberg Koppitz Graduate Student

Fellowship in Child Psychology

2014-2016 Doctoral Candidate


Miami, Florida

2015 Student Research Award Competition Honorable Mention

2015-2016 Clinical Intern

Medical University of South Carolina

Charleston, South Carolina

SELECTED PUBLICATIONS

Babinski, D.E., Waxmonsky, J.G., Waschbusch, D.A., Humphrey, H., Alfonso, A.,

Crum, K.I.,…Pelham, W.E. (2014). A pilot study of stimulant medication for adults with

ADHD who are parents of adolescents with ADHD: the acute effects of stimulant

medication on observed parent-adolescent interactions. Journal of Child and Adolescent

Psychopharmacology, 24(10), 582-585.

Detweiler, M. F., Comer, J. S., Crum, K. I., & Albano, A. M. (2014). Social anxiety in

children and adolescents: Biological, developmental, and social considerations. In S. G.

Hofmann, & P. M. DiBartolo (Eds.), From social anxiety to social phobia: Multiple

perspectives (3rd ed.). Boston, MA: Allyn and Bacon.

82

Miller, N.V., Haas, S. M., Waschbusch, D. A., Willoughby, M. T., Helseth, S. A., Crum,

K. I., Coles, E. K., & Pelham, W. E., Jr. (2014). Behavior therapy and callous-

unemotional traits: Effects of a pilot study examining modified behavioral contingencies

on child behavior. Behavior Therapy, 45(5), 606-618.

Waxmonsky, J. G., Waschbusch, D. A., Babinski, D. E., Humphrey, H. H., Alfonso, A.,

Crum, K.I., Bernstein, M., Slavec, J., Augustus, J. N., & Pelham, W. E. (2014). Does

pharmacological treatment of ADHD in adults enhance parenting performance? Results

of a double-blind, randomized trial. CNS Drugs, 28(7), 665-677.

Chou, P., Cornacchio, D., Cooper-Vince, C., Crum, K. I., & Comer, J. S. (2015). DSM-5

and the assessment of childhood anxiety disorders: Meaningful progress, new problems,

or persistent diagnostic quagmires? Psychopathology Review, 2(1), 30-51.

Crum, K. I., & Comer, J. S. (2015). Using synchronous videoconferencing to deliver

family-based mental health care. Journal of Child and Adolescent Psychopharmacology,

26(3), 229-234.

Crum, K. I., Cornacchio, D., Greif Green, J., Coxe, S., & Comer, J. S. (2015). Conduct

problems among youth exposed to the Boston Marathon attack: The moderating role of

violent crime exposure. Journal of Clinical Child and Adolescent Psychology. (Online.)

Crum, K. I., Waschbusch, D. A., Bagner, D., & Coxe, S. (2015). Effects of callous-

unemotional traits on the association between parenting and child conduct problems.

Child Psychiatry and Human Development, 46(6), 967-980.

Cornacchio, D., Crum, K. I., Coxe, S., Pincus, D. B., & Comer, J. S. (2016). Irritability

and severity of anxious symptomatology among youth with anxiety disorders. Journal of

the American Academy of Child and Adolescent Psychiatry, 55(1), 54-61.

Crum, K. I., Waschbusch, D. A., & Willoughby, M. T. (2016). Callous-unemotional traits

influence the nature of the student-teacher relationship and its association with long-term

outcomes. Journal of Emotional and Behavioral Disorders, 24, 16-29.

Waschbusch, D. A., Willoughby, M. T., Haas, S. M., Helseth, S. A., Crum, K. I.,

Altszuler, A. R., Ross, J. M., Coles, E. K., & Pelham Jr., W. E. (in press). Effects of

behavioral treatment modified to fit the learning style of children with conduct problems

and callous-unemotional (CU) traits. Journal of Consulting and Clinical Psychology.

Crum, K. I., Cornacchio, D., Coxe, S., Greif Green, J., & Comer, J. S. (accepted). The co-

occurrence of posttraumatic stress and conduct problems following the Boston Marathon

bombing: A latent profile analysis. Journal of Traumatic Stress.

Documents

Anxiety and Callous-Unemotional Traits: Physiological and